New Chat Application Procedure

To create a new MDAchat, first decide to volunteer as a host. Then, fill out the application form provided below.

MDAchat hosts have the following responsibilities:

• Make certain that at least one member of the host team is present at each chat session - begin and end chat sessions as scheduled.
  
  
• Help to encourage lively and productive online interchanges and discussion.
  
  
• Recruit and welcome new online participants.
  
  
• Invite special guests to join the chat session from time-to-time.
  
  
• Provide information about special guests and/or topics to the MDAchat administrator for appropriate prior announcement.
  
  
• Report problems or concerns as soon as possible to the MDAchat administrator, mdachat@mdausa.org.

MDAchat is a service of the Muscular Dystrophy Association (MDA) Web site. The focus of MDAchat is to encourage adults and children affected by neuromuscular diseases and their families, friends and caregivers — interactively — to share points-of-view, experiences and similar interests. Within the context of the MDA Web Site Disclaimer, MDA reserves the right, at its sole discretion, to establish MDAchat management, operations, content and participation policies for all online sessions and events. All MDAchat participants will be granted access via a password registration and agree to abide by the MDAchat User Policy. MDAchat groups have assigned schedules — as close as possible to those requested in this application. Such scheduling helps to ensure participants with common interests are online together and allows everyone to plan accordingly.

Chat Session Topical Name: ( 20 characters max. including spaces )

Chat Purpose/Description:

( 200 char. max including spaces )

Frequency:   Weekly   Monthly   Other (specify):

Day(s) of the week:

Sun  Mon  Tue  Wed  Thur  Fri  Sat

Local Start Time: ( include time zone, e.g., 9:00 AM Central )

Local Stop Time: ( include time zone, e.g., 9:00 AM Central )

Date you would like to start the chat:

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Full name (First, Initial, Last):
Organization name (if applicable):
US Postal street address:
City, State, Zip Code:

Day telephone:
Evening telephone:
Fax (if applicable)		Call ahead?	yes no

E-mail address(es)
MDAchat online nickname
Personal Web site address (if applicable)
Are you registered with an MDA local office?	yes no
If yes, what city and state:
Your age:
Neuromuscular disease you are most interested in?

How are you affected by this disease: ( check all that apply )

I have the disease

Parent of a child with the disease

Caregiver for someone with the disease

Friend or family member of someone with the disease

Doctor, researcher, or other specialist focusing on the disease

Concerned or otherwise impacted by the disease ( explain ):

Please Check one:

No host team - You have my permission to share my name and e-mail address with others who may wish to join me in hosting an MDAchat session. Then

I've formed a host team with two or three of my friends and secured their approval to provide information about them as requested in the form below.

TEAM MEMBER 1:

Full name (First, Initial, Last):
Organization name (if applicable):
US Postal street address:
City, State, Zip Code:

Day telephone:
Evening telephone:
Fax (if applicable)		Call ahead?	yes no

E-mail address(es)
MDAchat online nickname
Personal Web site address (if applicable)
Registered with an MDA local office?	yes no
If yes, what city and state:
Age:
How is this team member affected by the disease: ( check all that apply )
Has the disease
Parent of a child with the disease
Caregiver for someone with the disease
Friend or family member of someone with the disease
Doctor, researcher, or other specialist focusing on the disease
Concerned or otherwise impacted by the disease ( explain ):

TEAM MEMBER 2:

Full name (First, Initial, Last):
Organization name (if applicable):
US Postal street address:
City, State, Zip Code:

Day telephone:
Evening telephone:
Fax (if applicable)		Call ahead?	yes no

E-mail address(es)
MDAchat online nickname
Personal Web site address (if applicable)
Registered with an MDA local office?	yes no
If yes, what city and state:
Age:
How is this team member affected by the disease: ( check all that apply )
Has the disease
Parent of a child with the disease
Caregiver for someone with the disease
Friend or family member of someone with the disease
Doctor, researcher, or other specialist focusing on the disease
Concerned or otherwise impacted by the disease ( explain ):

TEAM MEMBER 3:

Full name (First, Initial, Last):
Organization name (if applicable):
US Postal street address:
City, State, Zip Code:

Day telephone:
Evening telephone:
Fax (if applicable)		Call ahead?	yes no

E-mail address(es)
MDAchat online nickname
Personal Web site address (if applicable)
Registered with an MDA local office?	yes no
If yes, what city and state:
Age:
How is this team member affected by the disease: ( check all that apply )
Has the disease
Parent of a child with the disease
Caregiver for someone with the disease
Friend or family member of someone with the disease
Doctor, researcher, or other specialist focusing on the disease
Concerned or otherwise impacted by the disease ( explain ):

Please read the following and then click the "Submit" button below to send your application. MDAchat privacy policy is that as a host, only your first name and chat nickname will be used for announcements. Should you wish to help host a chat but cannot form a team, clicking the SUBMIT button below grants MDAchat permission to share your name and e-mail address with others who are seeking to join or form a chat session. All other information you provide about yourself and other host team members will not be released without prior permission, except that MDAchat will release information to (1) those duly authorized to conduct criminal and other legal investigations and honor all court subpoenas and (2) MDA office and clinic staff and clinic physicians, research investigators and their staff affliated with MDA activities and programs. Alternatively, you may fax the application to 520-529-5383 or mail it to MDAchat Administrator, 3300 E. Sunrise Dr., Tucson, AZ 85718. Thanks for your interest in MDAchat.